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Pediatric Coding Alert

Avoid OIG Scrutiny While Increasing Revenue by 15 Percent

Published on Sun Sep 28, 2003

How to turn 'incident-to' services from confusing to profitable

The U.S. Health and Human Services Department's Office of Inspector General (OIG) continues to focus on services and supplies reported "incident-to" physicians' services as a part of the agency's Work Plan for 2003. Continued interest in these areas reveals the ongoing difficulty physicians and coders experience when documenting and reporting these services.
 
The agency will also continue to scrutinize all services billed for nonphysician practitioners (NPPs), noting that physicians are reporting such services four times as often in recent years as previously. Here again, providers must take care that NPP practice employees provide incident-to services within the parameters established by CMS and that NPP services meet scope-of-practice requirements.
 
The eligibility of NPPs to report incident-to varies widely from state to state, but the list below indicates some of the more commonly recognized NPPs.

NPPs allowed to report incident-to services (within their scopes of practice):

 

  •  Clinical Nurse Specialists
     
  •  Clinical Nurse Midwives
     
  •  Clinical Psychologists
     
  •  Clinical Social Workers
     
  •  Nurse Practitioners
     
  •  Occupational Therapists
     
  •  Physician Assistants
     
  •  Physical Therapists
     
  •  Speech Pathologists 

    Practices must comply with the intricate guidelines that regulate incident-to billing because repayment and fines can be steep. The good news, however, is that you can turn these OIG lemons into lemonade. By understanding and following the guidelines below, practices can increase their payment for incident-to services and avoid difficulties with the OIG.

    Recover an Additional 15 Percent

    Medicare's reimbursement policy for incident-to services allows you to report certain services rendered by NPPs under the supervising physician's number. The result: You receive reimbursement for those services at 100 percent of Medicare's allowable Physician Fee Schedule instead of 85 percent of the fee schedule allowed under the NPP's number, says Judith Richardson, RN, MSA, CCS-P, a senior consultant with Hill & Associates in Wilmington, N.C.
     
    Keep in mind that while NPPs can handle more in-depth services and bill incident-to, state regulations determine the allowed services they may perform. You should make sure your licensed NPPs follow the local regulations for prescribing, ordering tests, and performing other services.

    Play by the Rules - Win the Game

    Medicare has four incident-to guidelines:

     

  • The service(s) must be an integral, although incidental, part of the physician's professional service.   "This makes it clear that the doctor must be involved in the patient's care," says Michael Powe, director of health systems and reimbursement policy for the American Academy of Physician Assistants (AAPA). "The physician must personally treat, diagnose and develop a treatment plan on the patient's first visit to the practice for a particular medical problem. Subsequent care and services can then be delegated, and billed incident-to."

    The supervising physician must also personally treat and diagnose established patients who are being seen for a new problem or condition. Be aware that services by a NPP may be billed under his name and Medicare number if the incident-to billing requirements are not met. Medicare covers these services at 85 percent of the physician rate.

     
  • Incident-to services may be provided only in the physician's office, patient's home, or an institutional office setting.
     
    The term "institutional office setting" describes a location where a physician leases a portion of another institution - such as a room in a hospital - as temporary office space. When an NPP provides care in such a space, you may report it as incident-to.
     
    The 2002 CMS changes now permit billing incident-to for hospital visits, such as 99231-99233 (Subsequent hospital care). CMS Transmittal 1775 outlines the
    new rules.
     
    As a result of the change, your physician assistant (PA), as well as any other NPPs employed by the practice, can now bill an E/M for the morning rounds, if you visit the patient later that day. Incident-to rules, however, require the physician to initiate the plan of care.

     
  • The NPP must work under the physician's direct supervision.
     
    "This does not mean that the doctor must be in the same room with the NPP," Powe says, "but it does mean that the physician must be physically present in the suite of offices."
     
    Some doctors may have offices that connect with a hospital. They may simply walk through a door or hallway to get from one to the other. But if the physician crosses that boundary into the hospital, he can no longer be involved with the patient's care, according to Medicare.    

    Services rendered in their office area at that point cannot be billed as incident-to. Similarly, a physician's availability by phone does not provide sufficient involvement.

     
  • The physician and NPP must share a common employer.
     
    The physician and the NPP must be employed by the same practice or, if the physician owns the practice, the NPP must be an employee of that practice. In the event that the practice employs NPPs as independent contractors, the services delivered by the NPPs can't be billed incident-to. HCFA provides one exception to this rule for PAs, who are permitted to form independent groups, subcontract their services to multiple practices, and bill incident-to.

    Avoid Denials With the Following Guidelines

    When you report services rendered by NPPs as incident-to, you should follow these simple rules:

     

  •  Ensure that your place of service is correct. Remember, incident-to is only applicable for services performed in the facilities designated by Medicare.
     
  •  The patient does not have to be a new patient or have a new problem or condition.
     
  •  The supervising physician must be in the office suite, but doesn't have to be in the room where the NPP renders the service. (The supervising physician does not have to be the same one who initially saw the patient, as long as the physicians belong to the same practice, that is, are members of the same group.)
     
  •  The supervising physician must perform the initial service and ongoing services at a frequency that shows the doctor's continued active involvement in the patient's care. That's because the NPP is providing services that are integral to the physician's services, not a replacement for them.
     
  •  Your NPP's documentation must meet the same requirements as the physician's for the specific service.

    Experts also recommend that physicians sign NPP charts to document their presence while patients are still in the office. For their part, coders must ensure that the chart indicates the doctor's initial involvement in the patient's care and the development of a treatment plan.

    Take a Look at Some Examples

    The following scenarios provide examples of when incident-to can (or cannot) be billed:

    Scenario 1: A full-time PA sees a patient in the practice when the pediatrician involved with the patient's care is called away to the hospital. During the physician's absence, the PA performs a follow-up examination with a teen-ager who had undergone a minor procedure a week earlier.
     
    Coding solution:     You should report this visit directly under the PA's PIN with the appropriate established patient E/M code (99211-99215), unless the service falls within a global surgical period. You cannot bill the PA's services incident-to because the physician involved in the patient's care is not present in the office when the visit occurs.
     
    Scenario 2:     An established diabetes patient presents for a follow-up examination, and the practice's nurse practitioner (NP) performs an interval history physical exam with appropriate medical decision-making before the patient sees the pediatrician. While the NP is conducting the exam, the physician is seeing another patient in the office.
     
    Coding solution: In this case, you can report 99213, for instance, as incident-to because the physician has seen the patient previously.

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